Transcript STD 101 - STD Prevention Online

Kees Rietmeijer, MD, PhD
Denver Prevention Training Center
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 Provide
overview of the management
of the most common STD syndromes:
o Vaginal discharge
o Male urethral discharge
o Genital ulcer disease
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New edition expected in 2014
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Express Visit
o Eligible
• Asymptomatic
• Low-risk
o Testing
• All
• Chlamydia NAAT
• Gonorrhea NAAT
• HIV
• Based on risk
• Syphilis: RPR

Comprehensive Exam
o Eligible
• Symptomatic
• High-risk
• MSM
• Partner of STI
• Sex work
o Testing
• Based on symptoms
• POCT
• All
• CT/GC NAAT
• RPR
• HIV
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31 year old woman
Complains of abnormal, malodorous vaginal discharge
since 10 days
Over the counter medications have been ineffective
Last sexual contact 3 days ago with new partner
2 partners in past 3 months
Otherwise no health problems
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What else do you want to know?
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Only sex with men
Not aware of any partners’ symptoms
Inconsistent condom use
Previous STDs:
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o Chlamydia infection 2 years ago
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No substance use or sex work
Never been tested for HIV
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NUGENT Score 0
NUGENT Score 10
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BV
o
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Amsell Criteria
• Homogeneous,
grey discharge
• Whiff
• Ph >4.5
• Clue cells
o
Treatment
• Metronidazole/7d
• Tinidazole/7d
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Partner
management
o
Not recommended
Yeast
o
o
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Hyphae
Spores
Treatment
o
Azoles
•
•
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Not recommended
Trichomoniasis
o
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o
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Motile trichomonads
Treatment
o
Topical/5-7d
Oral/single dose
Partner
management
o
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Metronidazole/single
dose
Tinidazole/single dose
Partner
management
o
Yes
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Wet prep
Culture
Sensitivity
55%–65%
75%
Specificity
100%
100%
POCT (OSOM)
PCR (LDT)
TMA AptimaTV
>83%
83-92%
100%
>97%
100%
100%
ProbTec TVQ
98.3%
98.3%
Briselden AM. J Clin Microbiol. 1994; Demeo LR. Am J Obstet Gynecol. 1996;
Huppert JS. J Clin Microbiol. 2005; Nye MB. Am J Obstet Gynecol. 2009;
Van Der Pol B. J Clin Microbiol. 2006.
Van Der Pol; Schwebke; Taylor: Posters STI & AIDS, 2013
Courtesy: Charlotte Gaydos. ISSTDR, Vienna; 2013.
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Chlamydia and gonorrhea NAAT (e.g., APTIMA or
ProbeTec)
Syphilis:
o Traditional algorithm:
• Non-trepenamal (RPR or VDRL)
• If + followed by treponemal test (TPPA/TPHA/FTA)
o Reverse algorithm:
• Treponemal (EIA or rapid POC)
• If + followed by non-treponemal (RPR or VDRL)
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HIV
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24 year-old MSM
Urethral discharge since 3 days
Known HIV+
10+ partners in past 3 months
Last sex 2 days ago in bath house
Pt is “versatile”; i.e., engaging in both insertive and
recepetive anal inntercourse
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Patient is in HIV care and had an undetectable viral load
at last testing 2 months ago
Unprotected sex only with partners he knows are HIV+
as well
Has a history of multiple STDs, including syphilis and
gonorrhea
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Gonococcal Urethritis
Treatment
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o Azithromycin or Doxycycline
o Ceftriaxone +
o Azithromycin or Doxycycline
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Partners
Nongonococcal urethritis
Treatment
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Partners
o
o <60 days
o
o Evaluation and treatment
o
o Expedited partner
treatment (EPT)
<60 days
Evaluation and treatment
EPT
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Cause of Urethritis Among Males
Denver Metro Health Clinic
(N=7527)
17%
50%
26%
7%
Gonorrhea
Chlamydia
Both
Neither
Cause of Nongonococcal Urethritis
Seattle, 2007 - 2011
CT
MG
UU-2
TV
None
24%
38%
N = 606
13%
2%
Manhart et al. Clin Infect Dis 2013;56:934
23%
Treatment Results
Azithromycin Doxycycline
%
%
• C. trachomatis
• M. genitalium
• U. urealyticum
86
40
75
90
30
70
• Clinical Cure
80
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Manhart et al. Clin Infect Dis 2013;56:934
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Traditionally, clinical
diagnosis established on
basis of Gram-stained
smear of urethral discharge
at > 5 PMNs/HPF
However:
• Cut-off determined in
pre-HAART era
• Low-level infections may be accompanied by low-level
inflammatory response (especially for chlamydia)
• How does the Gram stain perform at different cut-off levels
when using chlamydia NAAT as the gold standard?
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N = 11,422 Gram Stains
Rietmeijer and Mettenbrink Sex Transm Dis 2012;39:18
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29 year-old woman
Very painful vulvar lesions, increasing in severity for past
4 days
Monogamous relationship with new partner since 3
months
Used condoms initially, but unprotected vaginal and oral
sex after both partners tested negative for STD
No history of STDs
Partner not aware of symptoms and also negative STD
history
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Syphilis
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o Point of care
• History
• MSM
• Contact
• Darkfield
• RPR
o Non-Point of care
• Treponemal test
• EIA
• TPPA
• FT-ABS
o Treatment
• 2.4 MU LAB
o Partner Management
Genital Herpes
o Point of care
• History
• Contact
• Clinical presentation
• (Tzanck)
o Non-Point of care
• Culture
• (PCR)
o Treatment
• Acyclovir/Valacyclovir/
Famciclovir
o Partner Management
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